MEDICARE: STEPHEN GRANT WAHLIG MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	R11480	IA
2	2085R0202X	Diagnostic Radiology Physician	A181018	CA
3	2085R0202X	Diagnostic Radiology Physician	1021841	MA

General Provider Information

NPI Number	:	1073170528
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHEN GRANT WAHLIG MD

Provider Business Mailing Address
First Line	:	PO BOX 24520
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10087-3720
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	41 MALL RD
Second Line	:
City	:	BURLINGTON
State	:	MA
Zip	:	01805-2204
Country	:	US
Telephone Number	:	781-744-8000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/21/2019
Last Update Date	:	06/18/2025

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